The Australian Transport Safety Bureau (ATSB) is Australia's national transport safety investigator. The ATSB's function is to improve safety and public confidence in the aviation, marine and rail modes of transport. The ATSB is Australia's prime agency for the independent investigation of civil aviation, rail and maritime accidents, incidents and safety deficiencies.

Avoidable Accidents No. 6: Experience won't always save you

As pilots, we are familiar with well-publicised events of aircrew who, as a result of their experience and exceptional airmanship, avoided what could have been a disaster and a tragic loss of life. Pilots, such as Captain ‘Al’ Haynes in command of a United Airlines Douglas DC-10 on a flight from Denver to Chicago in July 1989, that had the fan wheel of its number two (centre) engine disintegrate, causing a loss of all three of its hydraulic control systems — an unprecedented problem that made the aircraft nearly impossible to fly or land. Captain Haynes and his crew figured out how to gain some control of the plane and were eventually able to get the severely disabled airliner to the Sioux City, Iowa airport, where they crash-landed. The aircraft broke apart during the landing and although there were 112 fatalities, a remarkable 185 people survived the crash.

More recent events, such as the US Airways Airbus A320 under the command of Captain Chesley Sullenberger, an experienced pilot, who together with his co-pilot, successfully ditched their stricken aircraft in the Hudson River after both its engines lost power following multiple bird ingestion on takeoff from New York’s La Guardia airportin January 2009. All the passengers and crew were rescued from the floating aircraft without injury. Then there was the effort of Captain Richard de Crespigny and his crew after the Qantas Airbus A380 they were flying experienced an uncontained engine failure just after departing Singapore’s Changi airport in November 2010. They guided the heavily damaged aircraft back to a safe landing at Singapore, averting what could have been a major catastrophe.

There have been many other individual acts of outstanding airmanship where ‘experience’ clearly played a part in the safe outcome. At the same time, a closer analysis of events suggests that things other than experience alone had a hand in the outcome. Good training, focussed preparation, a readiness for the unexpected and good crew interaction also had a significant part to play. Unfortunately, those other factors go mostly unreported in our media and the impression is created that mostly it is an individual’s experience that makes the difference.

In the same way, in those tragic cases where the outcome was a fatal accident, many factors were in play. Naturally, media interest in an accident is heightened when it involves an experienced pilot who is also a well-known aviation identity. Although this adds a human interest aspect to the tragedy, the subsequent media reports often do little to assist a thorough understanding of the circumstances that led to the accident.

The following selection of occurrences, taken from the Australian Transport Safety Bureau (ATSB) archives1 over the previous 20 years, bears testimony to the fact that experience alone is not necessarily a protection against vulnerability to an accident.

Key messages

Fatal accidents can and do happen to experienced pilots, as the following examples illustrate. In some of these occurrences, very experienced pilots were undertaking

flying that involved much higher risk, and as a consequence found that, in those circumstances, their flying experience alone, was unable to help them avoid disaster. Other accidents involved experienced pilots who may have allowed factors other than their experience to influence their actions. Yet in other accidents, the pilot’s vast experience may have even led to decisions that, in hindsight, were associated with more risk than necessary.

The report provides some insight as to why experience alone will not always prevent a pilot from having an accident and provides awareness of the following.

Experience alone can never compensate for high risk activity.

Sound decision-making and experience are not necessarily synonymous.

Using pilot experience as mitigation for potential operational risks is inadvisable. If the risks are unacceptable for a qualified and competent pilot, there should be no reason for an experienced pilot to find it otherwise.

Attend to the three Cs — compliance, communication and complacency, and all the other human performance considerations. Experience cannot overcome the mental and physical limitations of humans.

Conclusion

‘Human beings, who are almost unique in having the ability to learn from the experience of others, are also remarkable for their apparent disinclination to do so.’

Experience, used wisely, can be extremely useful for avoiding accidents and invaluable in an emergency. Experience also allows a pilot in normal operation to anticipate events, allowing more time to review and monitor a flight without having to ‘sweat’ the details. However, as can be seen, experience does not give a pilot immunity from an accident.

Experienced pilots will no doubt be familiar with many of the events discussed in this report and should not assume they are any less vulnerable than the pilots involved in the accidents reported on these pages. Less experienced pilots can learn to avoid the pitfalls that can develop with their increasing experience. A pilot, no matter what level of experience, should never be beyond learning from the experiences of others.